Smart EHR Implementation Decisions Key to Usability Improvements

A panel of four healthcare leaders emphasized the importance of maintaining a focus on user-centered design during the EHR implementation process.

December 04, 2017 - Encouraging healthcare organizations and health IT companies to make smarter decisions during the EHR implementation process is the oft-overlooked but vitally important key to enabling EHR usability improvements, according to experts convened during the ONC Annual Meeting on November 30.

Gettinger framed the discussion by invoking the idea of EHR usability being a three-legged stool.

“The first leg is what our developer colleagues do when they develop software,” he stated. “The second leg is how institutions implement the software. And the third leg is the responsibility we have as users of the software to understand how it works.”

Improving EHR usability is increasingly important as federal regulations mandate that providers spend an inordinate amount of time sitting in front of their monitors for clinical documentation purposes during patient encounters.

Offering the nurses perspective, Freeman stated the provider burden that accompanies regulations surrounding clinical documentation sometimes requires nurses to enter anywhere from 200 to 2,000 data elements as part of a single patient’s physician assessment.

The number of data elements nurses must enter into EHR systems can rise depending on how much information a nurse gathers about a patient, as well as how many times a nurse is required to reenter the same data elements into the system to ensure information is available everywhere physicians or administration may need it.

“Rarely are they reusable,” stated Freeman. “So what you’ll hear from nurses a lot is, ‘I just entered that piece of data, but I have to put it in 14 times because it’s in different places.’ So the design of the entry system is not good.”

“And what that leads to on the backend is that you don’t have analytics that are good, because if you point to the wrong place and they’re not all tied together you end up with erroneous data,” she continued.

Excessive system customization choices during the EHR implementation process can muddle and confuse users, she said. Any poor decision-making during implementation can have long-lasting effects that negatively impact clinical efficiency.

“That includes failure to train appropriately, failure to follow up as you need to,” she said. “So there is a lot that happens in the implementation space that impacts usability and for nursing in particular I would focus on the fact that a lot of times when systems were built nursing was not the focus.”

Mason said ONC, Ratwani, and others at the National Center for Human Factors in Healthcare have been working together to assist in improving decision-making during the implementation process.

“We’ve contracted with Dr. Ratwani and others to create a resource or a change package that pulls together ways practices can identify and apply usability best practices during the EHR implementation process,” stated Mason.

While EHR usability entails both EHR system display and cognitive support, Ratwani emphasized that the cognitive support piece is the main component providers and health IT developers currently need to work together to improve.

“The cognitive support piece is providing the right information to the clinician to support their reasoning and decision-making,” said Ratwani. “That’s the core component of usability.”

Aspects of interface design and cognitive support are often changed during the EHR implementation process by specific healthcare organizations.

Similarly to Freeman, Ratwani cautioned against excessive customization. He stated that healthcare organizations and EHR vendors often undo decisions that were made by developers to improve EHR usability during the implementation process.

As an example, Ratwani provided an advanced glimpse into the results of a recent study conducted by the National Center for Human Factors in Healthcare. The full study is set for release in 2018.

Researchers observed differences in EHR use at two healthcare sites.

“The data are staggering,” stated Ratwani. “If you look at something like an emergency physician ordering an X-Ray, we see an eight-to-tenfold difference in ordering at sites using the same EHR vendor. That’s incredible. If you look at the number of errors that are happening, we see a two-to-threefold difference between sites.”

“Much of that is driven by the decisions made during implementation,” stated Ratwani. “That’s not where much of our attention has been.

Such a drastic difference in test ordering and medical errors between care sites using the same EHR system or system vendor points to a lack of standardization in EHR implementation processes.

“Now with ONC and this change package work, we’re seeing much more attention around implementation and what is happening there,” stated Ratwani.

The change package work focuses on building a tool that provider organizations can use to attain a base level of knowledge about usability. Improving education surrounding implementation and its effects on usability, as well as equipping providers with the tools and methods necessary to address usability challenges, could help to reduce burden on providers in all care settings.